MIDDLE TENNESSEE STATE UNIVERSITY

 PARTNERS IN EDUCATION

 STUDENT AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION

This form allows students to authorize the release of confidential academic, financial aid and student account information to a third party.  If you have questions regarding Partners in Education (PIE), please contact the Academic Support Center at (615) 898-2339 or come to the Center’s office which is located in the McFarland Building.  

**AUTHORIZATION – THIS MUST BE SIGNED AND DATED IN ORDER FOR INFORMATION TO BE RELEASED**

I authorize the release of confidential academic, financial aid, student financial account information, academic progress reports and grades (when available) to the person(s) named in the following information.  This release does not apply to other information (counseling and health) protected by the Family Educational Rights and Privacy Act (FERPA).  Authorization is valid as long as the student is enrolled at Middle Tennessee State University or until cancelled in writing by the student.  To cancel this release, the student must contact the Academic Support Center at (615) 898-2339 for instructions.

             

                    1. _______________________________________________________________    _______________________

                                Student’s Signature                                                                                  Date

IMPORTANT:  The following information MUST be completed to assist University staff in identifying the student and non-student Partner when he/she calls to request information by telephone.

2. Student’s Name (please print clearly):	_____________________________________________________________________________
3. Student’s 8-digit MTSU ID M#: (ID numbers are found on student ID card and on the student’s RaiderNet account)	M ___  ___  ___ ___  ___  ___  ___  ___

**INFORMATION ON DESIGNATED PIE PARTNERS**

PIE Partner Name(s) Person(s) other than student authorized to request/receive information. Please print:	Personal Identification Number PIE Partner: choose a 4-digit number to identify yourself to our staff.  Choose a 4-digit number that you will easily remember.
.	.
.	.

Email address to which information should be sent: ______________________________________

Address to which requested information should be sent (If you prefer information sent by mail notify us at (615) 898-2339):

_____________________________________________________________________________

(Number and Street)

_____________________________________________________________________________

(City)                                                                               (State)                                           (Zip)

(        )                                                                                                                                                  

(Telephone Number)

Mail this form (do not fax) to Academic Support Center, MTSU box 94, Murfreesboro, TN 37132. Attn: PIE